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Afraid I'll get stuck with a crappy machine because of my insurance
well, i go back to the sleep clinic tomorrow to discuss the results of my sleep study. im sure he will prescribe a cpap machine. this leads me to worry about my crappy insurance. i have already talked to one dme that takes my insurance and all he did was gripe about dealing with that company. he also told me they will only pay for one kind of machine and one kind of mask. my question is, what if my doctor prescribes something else? what if i get stuck with a crappy bottom of the line machine? is there anything i can do about it? i wonder if all dme places will tell me the same thing? no onwe in the town im from will even take this insurance.
sorry about the lack of capitalization and punctuation. doing this from my phone and it doesnt work so great for this sort of thing.
Views: 371
Replies to This Discussion
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Permalink Reply by Jason on
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You could alway complain that the machine you have is not doing the job to your doc. A good doc would prescribe something that suites you.
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Permalink Reply by Moe on
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See if the dme will loan you a machine for a month or so to get used to a good one. Or if they have a rental plan of some sort. Of course the mask to be purchased but part of the fitting procedure should include a few styles to try in order to find one that feels comfortable - make sure to try lying on your side for a few minutes and if you have any doubts, try another mask...my experience is the mask is more of deal breaker than the machine--make sure it fits right and feels right.
I'm no expert but the difference between a bottom of the line machine and top seem to be mostly bells and whistles. Humidifier is nice but, depending on where you live, not essential. Ramp-up pressure is also nice, but again, once you've adjusted to having the machine and mask, not essential.
The reason to see if there is a loaner CPAP available is to try it out and see what you like. Then...if you're strapped for cash (and who isn't) you can look for upgrade machines on EBay or your local online Used...List.
You can also go to war with the insurance company, appeal their decision to fund and, depending on where you work, see if your Human Resources team or other management will line up on your side with a letter or two.
Good luck.
moe
“It's better to have loved and lost than to have to do forty pounds of laundry a week.”
Laurence J. Peters
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Permalink Reply by Mary Z on
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Take a deep breath. First of all that DME was totally out of line to fill you with doubts and fears before you even have the prescription. See what you get before you freak out. As others have given good suggestions about how to handle this, and alternatives if the machine and mask are not satisfactory I won't repeat that information., Many of us have chosen to go out of pocket to try different masks and to have stand by machines. This doesn't have to be terribly expensive.
Best of luck tomorrow, I hope everything comes out alright.
Let us know tomorrow how the visit to the sleep clinic goes.
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Permalink Reply by Claude on
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I agree with Mary Z. That DME was totally out of line to fill you with doubts and fears before you even have the prescription. See how it goes and at least give it a chance before closing your mind to making this work. Good luck at your appointment. Let us know how it goes.
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What the DME company means is that most insurances are not going to pay for a machine with "bells and whistles" on it. Tehre is no need for it. There are some insurance companies who do state a specific manufacturer though. As for masks I have never heard of an insurance dictating a specific mask type....these are coded items and the insurance pays for it via code..not mask type. It seems you DME you are working with is not very knowledgeable. I work in DME in sleep as an RT and we do have difficult insurances but they they all will pay for a machine and mask. You may want to find another DME if at all possible. If you aren't able to, don't take their initial word...fight. I fight all the time for my patients to get the equipment they need and that should be the job of your DME company.
Any other questions let me know.
Jennifer
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Permalink Reply by Rooster on
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Here is something that I put together for newly diagnosed patients.
Questions to ask about your PSG and Titration Study
1. Did I have any central apneas? How many?
2. Were there any comorbidities? What were they?
3. Did I breathe or leak through my mouth? How often? What do you recommend to prevent it?
3. Did I exhibit Positional Sleep Apnea (PSA)? Was my apnea more severe in one sleeping position as compared to others? Is my pressure requirement higher in one position as compared to others? (Often sleep apnea is more severe when sleeping on the back.)
4. Is there anything else unusual about the results?
5. How will I know my therapy is preventing apneas?
6. I am determined to own a data-capable machine and software to monitor apneas, hypopneas and mask leak. This will allow me to call your office with specific questions if I have problems with the therapy. Will you help me with the appropriate prescription?
In addition to the questions:
1. Get a copy of your PSG. It is your legal right to have one.
2. Get a copy of your CPAP prescription.
3. Make sure the prescription calls for a humidifier with the machine.
Remember, this therapy depends on you for success. The doctor is being paid to help you, not control you. You must take control.
If you "get stuck with a crappy machine", it is your own fault. Be prepared to put your hands in your pockets and walk out the door with the machine still in the hands of the DME minion.
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Permalink Reply by Allison Keller on
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Sitting in the waiting room now. It is appointment time. Will post results tonight from home or later from the phone if I have time. THANK YOU ALL FOR YOUR REPLIES. You have helped me keep from worrying about this too much. I think I will go to a different DME. I believe that is sound advice.
Wish me luck!
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Permalink Reply by S Miller on
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I had a "bottom of the line" machine when I first started on my CPAP, and a choice of only 2 masks. I used it because I needed it so bad, and it did work. I have to tell you though, I did upgrade my mask to a gel mask this past few months...it did cost me some out of pocket money, but was so well worth it.
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I agree with Moe - the mask is the deal breaker. If the mask doesn't fit well, then it doesn't matter what level machine you have - it can't do it's job. You can get used or used but really new-never used masks at places like www.cpapauction.com. The higher-end machines just include extras like the SD cards (just a tool for your Dr. to determine compliance), humidifier (nice, but not necessary), ramp (again, nice, but not necessary), heater, etc. They don't effect the actual functioning of the pressure of the machine.
Good luck at your appointment! Hope everything works out.
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Permalink Reply by 99 on
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these are excellent questions except put these questions to your doctor ask you dr to write a specific script for an apap
clinations manual software for apap and a reader
Rooster said:Here is something that I put together for newly diagnosed patients.
Questions to ask about your PSG and Titration Study
1. Did I have any central apneas? How many?
2. Were there any comorbidities? What were they?
3. Did I breathe or leak through my mouth? How often? What do you recommend to prevent it?
3. Did I exhibit Positional Sleep Apnea (PSA)? Was my apnea more severe in one sleeping position as compared to others? Is my pressure requirement higher in one position as compared to others? (Often sleep apnea is more severe when sleeping on the back.)
4. Is there anything else unusual about the results?
5. How will I know my therapy is preventing apneas?
6. I am determined to own a data-capable machine and software to monitor apneas, hypopneas and mask leak. This will allow me to call your office with specific questions if I have problems with the therapy. Will you help me with the appropriate prescription?
In addition to the questions:
1. Get a copy of your PSG. It is your legal right to have one.
2. Get a copy of your CPAP prescription.
3. Make sure the prescription calls for a humidifier with the machine.
Remember, this therapy depends on you for success. The doctor is being paid to help you, not control you. You must take control.
If you "get stuck with a crappy machine", it is your own fault. Be prepared to put your hands in your pockets and walk out the door with the machine still in the hands of the DME minion.
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I asked for a specific machine from the Dr and got it in writing. When the DME gave me their machine I returned it and offered to pay the difference than what the insurance allowed. A week later I had my machine. I never did get the software as the real test was a good night's sleep.
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Permalink Reply by Andy on
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Hi Allison,
Your last post was about an hour ago, so 'm hoping you're on your way home with good news!
Unfortunately, this whole apnea/CPAP thing is frustrating, but not impossible.
I've had relatively good experience with my doctor, insurance company, and DME, but not without problems.
I won't repeat my story here (you can search on this site, if you'd like) but I will tell you this. When it comes to the doctor and the insurance company and the DME, remember this phrase: "No means 'Not yet.'"
When the insurance company tells you, "No, you can't get that machine." it only means you haven't talked with the right person yet.
When the DME says, "No, that's the only mask you can have." it only means you haven't talked with the right person yet.
Just remember, the insurance company wants to pay out the minimum possible, and the DME usually wants to do the minimum work possible.
I had to talk with three or four people at my insurance company until I finally obtained a schedule of allowable payments from them. I had to ask the same person five times, before she would finally tell me that I would own the machine after a few months. I had to talk with four people at the DME before I could get them to send me the supplies I wanted.
Now that I have this all figured out, I order replacement masks, tubing, filters on the day the insurance company allows payment, whether I want/need them or not. That way, if/when they ever stop paying, I've got supplies that I need.
Bottom line is, it's your health, and you're going to have to push for what you need and want. Don't believe anyone when they say "no" just keep asking until you get "yes."
Please let us know how your appointment went, and please keep in touch. Especially if you're having any trouble.
Good Luck!
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